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COLLEGE STUDENTS
By
Chloe Brown
A Thesis
Presented to
In Partial Fulfillment
Counseling
May 2012
ONLINE COUNSELING: ATTITUDES AND POTENTIAL UTILIZATION BY
COLLEGE STUDENTS
By
Chloe Brown
COLLEGE STUDENTS
Chloe Brown
Student needs at college counseling centers are outpacing current resources. Key
organizations such as the American Psychological Association and the California higher
advances into current practice standards. This study explored college students’
knowledge of and interest in online counseling as well as provided useful information for
colleges interested in offering online services. College students (N = 119) completed the
developed by the researchers. The majority of the sample was female (71.4%, n = 85),
White (62.2%, n = 74), aged 18-25 (83.2%, n = 99), and had declared a social sciences
major (63.0%, n = 75). Results demonstrated promising student interest with 28.9% of
participants stating they had utilized online counseling and 64.4% endorsing online
counseling as a good alternative for their mental health needs. Most participants (77.3%)
said they would agree to provide relevant contact information for a crisis. As expected,
iii
r(119) = .498, p < .01. Interestingly, a small but significant correlation was also found
between general help-seeking behavior and online counseling attitudes, r(119) = .177, p =
.001. Gender differences consistent with counseling literature emerged for face-to-face
but not online counseling; females reported more favorable general help-seeking t(117) =
3.362, p = .001, and perceived value of face-to-face counseling t(117) = 2.295, p = .024,
attitudes. Differential results for face-to-face and online counseling suggest that students
perceive online counseling differently and that it may be useful for college counseling
centers to provide education about the two forms of therapy. For example, to increase the
incorporated into new student orientation with additional tutorials found on the college
counseling suggests that different will not necessarily deter people from utilizing online
support and that online counseling may be a worthwhile endeavor for college counseling
iv
ACKNOWLEDGMENTS
To begin, I would like to thank my advisor, Dr. Beth Eckerd for her continual
support, guidance, and faith in my abilities throughout this entire process. I could not
members Dr. Jennifer Sanford and Dr. Tasha Howe for their helpful feedback and
flexibility in meeting. Two other key players in this project were my undergraduate
assistants Vanessa and Colleen who contributed to the formulation of the hypotheses,
data collection and presentation of the finding at the Western Psychological Association
2012 Conference. I hope it was a valuable experience and encourages them to conduct
their own research in the future. Thank you to my colleagues, Anabel, Bill, Fritzie,
Francis, Jen, and Joey for your friendship and contribution to my development as a
therapist. To my housemate Nicole, thank you for your words of encouragement as I got
ready to sit down at my computer and tackle my next thesis draft. Lastly, I would like to
express my love and appreciation to my family and friends. Thank you for your endless
v
TABLE OF CONTENTS
ACKNOWLEDGMENTS .......................................................................................................... v
TABLE OF CONTENTS........................................................................................................... vi
Summary .............................................................................................................................. 29
Hypotheses ........................................................................................................................... 31
Participants ........................................................................................................................... 34
vi
Procedure .............................................................................................................................. 35
Measures ............................................................................................................................... 35
REFERENCES ......................................................................................................................... 72
APPENDIX A .......................................................................................................................... 82
APPENDIX B .......................................................................................................................... 83
APPENDIX C .......................................................................................................................... 84
vii
LIST OF TABLES
Table 1: Relation of Gender, Access Conflicts, and Internet Time to Belief that Online
Table 2: Relation of Gender, Access Conflicts, and Internet Time to Use of Online
f2f Counseling (FC-V), and Perceived Value of Online Counseling (OC-V) ............................. 46
Table 8: Mean Differences for Perceived Value of (OC-V) and Discomfort (OC-D) with
Technology/Services ................................................................................................................ 56
viii
Table 11: ANOVA Results for Perceived Value of Online Counseling (OC-V) by
Table 12: ANOVA Results for Perceived Discomfort of Online Counseling (OC-V) by
ix
1
CHAPTER ONE
INTRODUCTION
reported by college students seeking counseling services are on the rise (Benton,
Robertson, Tseng, Newton, & Benton, 2003; Mowbray et al., 2006). According to
have a diagnosable mental illness. A recent annual survey of college counseling center
directors (N = 320) noted a 70.6% increase in crisis issues over the past five years
students with an eating disorder, and a 39.4% increase in cases involving self-injury
Major Depressive Disorder, Bipolar Disorder, and Schizophrenia often occur late in
adolescence and early adulthood right as individuals are beginning college (Chisholm,
1998). With the effectiveness of new psychiatric medications and the continued
assistance of mental health supportive services, many of these individuals are now able to
continue their education. Unfortunately, many university counseling centers also report
limited resources to adequately support individuals with these more severe conditions
In the state of California, the four-year public higher education system is not
immune to these national trends. Extensive systemwide research at both the University
2
of California (UC) and California State University (CSU) systems indicate that students
are reporting mental health issues with greater frequency and complexity. For example,
data collected from three recent academic years (2005-06, 2007-08, and 2008-09)
indicate that the number of students seen at the college counseling centers on twelve CSU
campuses (only 12 out of the 23 CSU campuses maintained data) increased by 16.5%
with only a 7.6% increase in enrollment during the same time period (California State
counseling services have also been affected by severe budget cuts resulting in longer
student wait-times, difficulty retaining staff, and decreased services and programs within
both university systems. In the UC system, students who do not identify themselves as in
imminent crisis must often wait three to six weeks to see a counselor (University of
To meet the needs of students seeking counseling services, the roles, functions,
and standards of college counseling centers are continually changing. The UC and CSU
systems have worked creatively to adequately address increasing student demand through
crisis management teams, campus-wide collaborations (e.g., training for faculty and
plan of increased funding for student mental health services by increasing student
registration fees, resulting in an $8 million funding increase for the 2008-09 academic
year (University of California, University Affairs, 2008). In June 2007, voter approved
programs for public schools with approximately $34 million allocated for universities
3
(University of California, University Affairs, 2008). Adapting to the rapidly changing
collegiate environment has now also prompted the UC and CSU systems along with
alternatives to the traditional 50 minute face-to-face (f2f) session. In a final report by the
Select Committee on Mental Health, the CSU system made the following statement:
2010, p. 46)
level is online counseling. The college population uses online and media communication
extensively, and the majority of students either have no insurance or are limited in their
ability to afford healthcare services (Khasanshina, Wolf, Emerson, & Stachura, 2008;
In the private sector and at a few selected college counseling centers, the
traditional 50 minute f2f therapy model is now expanding to include online technology
experienced clinicians are exchanging emails with clients they see in f2f therapy or even
4
operating their entire practice online using a continuum of communication tools (e.g.,
college level, online counseling has the potential to meet the needs of students presenting
with typical college adjustment or other developmental concerns that are greatly
considerable number of these students are waitlisted and sometimes not seen by a
conclusions derived from most quantitative studies indicate that online counseling is just
as efficacious as f2f therapy and is becoming widely accepted within the mental health
field (Kraus, 2010). Research also suggests that online counseling can adequately
address a wide range of mental health conditions (e.g., depression, panic disorders,
substance abuse, eating disorders, and smoking cessation) [Barak, Hen, Boniel-Nissim, &
Shapira, 2008] and that a strong therapeutic alliance can be created and maintained
principles and best practices for online counseling, future directions for this developing
field include improving service quality and access and improving the research methods
used to study the effectiveness of online counseling (Cartreine, Ahern, & Locke, 2010).
Research exploring public attitudes and pinpointing those people most likely to be
interested in utilizing online mental health support is more limited than research
5
evaluating the efficacy of or client satisfaction with online counseling. Preliminary
locus of control, perceptions of stigma, and level of distress) between people who prefer
to utilize f2f counseling in comparison to people who prefer to utilize online counseling
services (Klein & Cook, 2010; Tsan & Day, 2007). Several studies focusing on the
college population (e.g., Klein & Cook 2010; Proudfoot et al., 2009; Richards, 2009;
Ryan, Shochet, & Stallman, 2010) found evidence that young adults preferred or were
willing to use more informal forms of mental healthcare such as informational websites
or online counseling but that the majority of participants lacked sufficient understanding
and awareness of what online services may offer to fully utilize such support. For
example, Hass et al. (2008) determined that 279 students (24.0%) out of a total of 981
respondents to an online outreach service for students at risk for suicide engaged in one
or more anonymous online dialogues. These findings suggest that college students may
be willing to utilize online counseling, but that student exposure to the possibilities and
the influence of new technology and communication. College counseling centers are in a
position to advance the field of online counseling due to current fiscal constraints and
high student demands for mental health services. Before choosing to offer online
methods, understand which students would most likely use such support, and identify
client anxiety due to delays in response time, and clinicians’ ability to protect clients in
immediate crisis, for example in cases of suicidal or homicidal risk (Yahpe & Speyer,
2010).
More research is now needed to expand on existing empirical data, and continue
interest in and attitudes towards online mental health services to guide program
development. The current study explored students’ knowledge of and interest in online
items developed by the researcher will gather specific information regarding student
individual student and a counselor. Several nonspecific questionnaire items also inquired
room discussions, and peer support groups. Although positive attitudes towards online
psychological help may not necessarily translate to actual utilization of such services
(Ajzen, 1991), acquiring this information may encourage discussion about how to best
meet student needs and expand outreach efforts to students less inclined to seek online
support. After defining terms, the following review of the literature for online
concerns, and training requirements for interested clinicians. A final section will discuss
the initial success of online services currently being offered on select colleges and health
LITERATURE REVIEW
psychotherapy (Barak, Klein, & Proudfoot, 2009). The term “online counseling” in this
Internet-assisted modalities including email, chat (e.g., instant messaging or chat room),
emailing, message boards, and weblogs where the therapist and client are not
communicating with each other in tandem and time is a fluid entity. Neither participant
has to be at the computer at the same time, and each has a chance to consider how and
when to respond to the interaction (Yaphe & Speyer, 2010). In synchronous interactions,
written or spoken dialogue occurs in “real time” when both the therapist and client have
common method of online counseling as a relatively good working computer and internet
9
connection are all that are required (Recupero & Harms, 2010). For this reason, the
current study will focus on the implementation of email counseling services on college
campuses. The published research on email counseling since the 1990s can provide
precautions. Furthermore, due to the current economic and staff limitations on college
campuses, email counseling services would require the least commitment of new
resources such as new computer software, as email is one of the main forms of
require more professional monitoring (e.g., being at the computer at a designated time
and screening discussion boards for potentially harmful information) and potentially
more computer software than is currently obtainable. Exploring some of these newer
forms of therapeutic intervention would be the next step if students responded positively
to an email online counseling program and funding were available to acquire any needed
computer software.
convenience and increased access for clients and therapists, the ability to overcome
geographical, physical or lifestyle limitations including time constraints, and the capacity
to save a transcript of the interaction (Barak et al., 2009; Rochlen, Zack, & Speyer,
as a gateway to f2f therapy (Richards, 2009). For example, at a college that offered an
online outreach service for students at risk for suicide, 190 students (19.4%) out of a total
of 981 respondents to the program eventually saw a counselor for an in-person evaluation
(Haas et al., 2008). A final benefit is that the act of writing may itself help a client
concerns have been noted, however, and include technological failures, the time delay,
2009).
technology began to have a significant impact in the field of clinical psychology during
the late 1990s, clinicians interested in practicing online did not have computer specific
2004). For example, the asynchronous nature of email interactions allows both the
clinician and client a greater degree of self reflection. The ability to save email messages
also allows the client to review previous therapy conversations and clarify
(Rochlen, Zack, & Speyer, 2004). Furthermore, it has been suggested that the typing
may work as an externalizing mechanism (e.g., client is able to see what they are
11
thinking/feeling on the computer screen) and lead to greater therapeutic change (Yaphe &
Speyer, 2010). From the clinician’s perspective, written documentation of therapy makes
easier as entire email interactions can be sent to one’s supervisor or colleague for
also be anxiety provoking and difficult to maneuver. Key concerns include the time
delay and disparities in writing ability between the clinician and client (Barak et al.,
2009). For example, if a client sends an email on a Friday evening, after the standard
Monday-Friday 9am-5pm work week, would a counselor not respond until Monday
already suffering. Also, differences in writing abilities between clinician and client can
empathy and a caring stance are not effectively communicated to the client through
writing (Recupero & Harms, 2010). To overcome these possible writing and technical
complications, it is important that clinicians clearly state expected email turnaround times
Society for Mental Health Online (ISMHO) encourages clinicians to assess clients’ skills,
attitudes, and past experiences with writing prior to the start of treatment (ISMHO, 2011).
The absence of face-to-face cues. Absence of f2f cues is one of the most drastic
differences between text-based and traditional f2f counseling modalities. In f2f therapy,
facial expressions provide important information about how the receiver understands,
12
interprets, and emotionally reacts to the words that were just spoken. Suler (2010) states
that communicating solely through text will have different implications depending on
such factors as the client’s preferred mode of interaction and presenting problem. The
lack of visual cues for some clients may create ambiguity, inhibit intimacy, and produce
anxiety as one is left to imaginative thinking to fill in the gaps of what cannot be “seen”
on the computer screen. To the contrary, the text-based environment may appeal to some
people and can help to contain over-stimulation in people experiencing trauma, social
anxiety or other issues involving shame and guilt (Leibert, Archer, Munson, & York,
2006).
methods to identify, understand, and communicate feelings and emotions that do not rely
on nonverbal body language. Active online consumers are right in the middle of this
depth in online relationships include: changes in text font, size or color, voice
accentuations (e.g., *ANGER* to indicate a vocal emphasis), trailers (e.g., as…, uh…,
and um… to indicate a hesitation or break in one’s train of thought), acronyms (e.g., lol
for “laugh out loud”), and exclamation points to emphasize emotion or lighten the mood
(Suler, 2010). Murphy and Mitchell (1998) also state that emotional writing can be
achieved by providing clients with images (e.g., I [therapist] am jumping up and down in
excitement for what we have achieved through our interactions today), or incorporating
figurative language (e.g., metaphor and symbols) into the writing. Unfortunately, people
effectively with clients online, it is important that clinicians notice client’s writing style
and then mirror their use of expressive writing techniques (Derrig-Palumbo, 2010).
professionals report online clients are able to express themselves more openly and
disclose higher levels of personal information at a quicker pace (Yaphe & Speyer, 2010).
Referred to as the “disinhibition effect” by many researchers (e.g., Richards, 2009; Suler,
2010; Yaphe & Speyer, 2010) the phenomenon is possibly due to people feeling less
counselor is also evident among the college population. For example, out of 50 email
center during a 14-month period, five related to suicidal ideation, six disclosed feelings of
counseling, it generally takes clients several sessions to disclose such information; only
five individuals emailed a counselor more than once, suggesting that the majority of
students disclosed highly sensitive information at the first point of contact (Richards,
2009). In an online method of outreach to college students at risk for suicide, one student
for a car accident I caused over 4 years ago, and the woman wants way
more money than we have, so it will affect me for the rest of my life—
another reason why I don’t think it’s worth sticking around. I think the
from both of these services suggest that users are comfortable in disclosing highly
sensitive material. Samaritan research indicates that service users expressed feeling
suicidal, disclosed that they had a suicidal plan, or expressed having made a suicide
attempt in 40.3% of email contacts and 48.4% of sent text messages (using a cell phone
or other mobile device) [Samaritans, 2010]. These figures compare with an average of
19.2% of users disclosing past or in progress plans of self-harm across all other methods
synchronous modalities for crisis management would provide a chance for continuous
dialogue that is not possible with email formats, and online peer group supervision would
and/or benefit from online counseling is another important component of planning for
providing online treatment. Comfort with and acceptance of online counseling will most
15
likely fall on a continuum with some individuals readily accepting of and excited to try
the new counseling medium, to individuals showing some interest but not having a space
that allows for confidentiality, to other individuals thinking that forming a meaningful
suitable for online counseling are people seen in outpatient settings, while those generally
thought not appropriate are people experiencing severe pathology (e.g., suicidal ideation,
programs (Kraus, 2010; Stofle, 2001). Specific conditions that have been shown to be
subclinical difficulties (e.g., Murphy et al., 2009), major depressive disorder (e.g.,
Vernmark et al., 2010), post-traumatic stress disorder (e.g., Klein et al., 2010; Sloan,
Gallagher, Feinstein, Lee, & Pruneau, 2011), social phobia (e.g., Andrews, Davis, &
Titov, 2011; Tillfors et al., 2008), eating disorders (e.g., Gulec et al., 2011; Lindenberg,
Moessner, Harney, McLaughlin, & Bauer, 2011), and smoking cessation (e.g., Hutton et
In a college setting, students likely to benefit most from online counseling include
students presenting with mild concerns (e.g., mild depression, developmental concerns,
and academic conflicts) that are put on a waitlist and unable to meet with f2f counselor
right away. Students with such issues may only need validation and direction which may
take as little as one email session. Furthermore, these concerns affect a large proportion
online forum accessible to all students may act as a measure in preventing more serious
16
mental health concerns. Other students who seek anonymity for fear of too much
exposure at one time (e.g., victims of sexual abuse, members of the LGBT community, or
students who believe there is something terribly wrong with them) may also find online
established, offering online treatment to people with serious mental health concerns is
likely to be ethically too risky for the majority of practicing clinicians. Based on the
work of online suicidal crisis/outreach programs (e.g., Haas et al., 2008; Ryan et al.,
2010; SAHAR, n.d.; & Samaritans, n.d.) it appears that treating suicidal clients is
providing the groundwork and crisis management practice needed to move in the
direction of meeting the needs of more at-risk clientele. At the college level, addressing
the needs of at-risk students through online counseling becomes a complex issue. It can
be argued that online counseling for a student in moderate to severe emotional distress is
probably better than having no contact with a mental health professional. College
campuses however, have a responsibility to keep students safe and minimal staff
resources and limited ability to respond immediately to email messages may entail
response methods are developed it is very possible that treating more at-risk students is
Research Outcomes
online counseling indicates that this new treatment modality is comparable to f2f
counseling with similar treatment outcomes (Barak et al., 2008; Murphy et al., 2009).
17
The few studies examining client interest and use of online counseling suggests that the
general public (including the college population) is interested in and willing to try online
counseling but that the majority of people lack an awareness and/or understanding of how
online counseling works (Klein & Cook, 2010; Murphy et al., 2009). The following two
sections summarize the current empirical findings regarding online counseling. The
knowledge gained from such research can then be applied to establishing a reasonable
standard of care.
studies [published anytime until March 2006] investigating the effectiveness of various
treatment outcome was measured differently across studies, Barak et al. (2008) found an
overall effect size (ES) of g = 0.53 which is considered to be a medium effect (Cohen,
1988) and similar to the ES found in studies examining the effectiveness of f2f
counseling (Lambert & Ogles, 2004). When examining the data for 27 studies which
with a therapist, the reported ES was g = 0.51 and g = 0.53 for email and chat
interventions, respectively (Barak et al., 2008). Similarly, Murphy et al. (2009) found
Satisfaction Survey scores for clients receiving either f2f or online counseling for a
variety of concerns (e.g., work stress, marital problems, anxiety/depression, and parenting
issues). These findings suggest that online counseling is becoming a viable treatment
treatment of several specific disorders. Barak et al. (2008) found a higher ES for issues
that were more psychological in nature (e.g., depression, anxiety, and body image) than
for concerns that were primarily physiological or somatic such as weight loss or reducing
blood pressure. The average ES as measured by several types of outcome measures (e.g.,
various psychological disorders reported in Barak et al. (2008) included g = 0.88 for
PTSD (N = 148), g = 0.80 for panic and anxiety disorders (N = 498), g = 0.45 for body
image concerns (N = 221), and g = 0.32 for depression (N = 2500). In contrast, the
average ES (using the same outcome measures) for weight loss and physiological
concerns was g = .17 and g = .27, respectively (Barak et al., 2008). Online counseling
may also be particularly appealing to individuals with social anxiety and avoidant
personalities due to the fear of seeking and meeting a therapist. Andrews (2011) reported
comparable results for f2f counseling and internet cognitive behavioral therapy for social
(the Social Interaction Anxiety Scale and the Social Phobia Scale). Supporting these
results, Tillfors et al. (2008) determined that internet delivered self-help for social phobia
and public speaking fears among college students was just as effective with and without
live group exposure sessions. The reported average within-group ES on primary outcome
measures (the Liebowitz Social Anxiety Scale self-report version, the Social Phobia
Scale, the Social Interaction Scale, and the Social Phobia Screening Questionnaire) at
19
post-test for the participants who received group exposure and the participants who only
received the self-help online material was d = 1.01 and d = 1.00, respectively.
The above results are encouraging as it is fairly common that individuals with
social anxiety are unable to initiate or participate in f2f counseling (Kessler, 2003).
number of fears and seeking treatment. Out of the respondents with pure social phobia (n
= 213), treatment was accessed by 25.9% of individuals with 1-4 fears, 16.6% of
respondents with 5-7 fears, 14.3% of individuals with 8-10 fears, and 8.4% of
respondents with 11 or more fears (Ruscio, Brown, Chiu, Sareen, Stein, & Kessler,
2008). Therefore, the key is finding a method of treatment that individuals with social
anxiety are able to access given possible social limitations. If an individual is unable to
seek f2f counseling initially, online counseling may be an acceptable first step for
professionals, given the lack of contact inherent with online counseling are also
concerned that clients will learn to utilize interpersonal skills over the internet that are not
then subsequently applied to f2f counseling sessions and other everyday interactions
In light of these findings, the current study will incorporate survey items that
assess participants’ comfort in discussing personal problems in f2f counseling and if they
would be interested in seeking online support for symptoms related to social anxiety,
including not having close friends and/or being shy or uncomfortable in social situations.
20
If a method existed of insuring that social competency skills were applied to everyday
interactions, online counseling for social phobia could potentially increase access to
evidence-based therapies and reduce the time required by therapists to administer the
treatment. Andrews (2011) noted a substantial difference in the amount of therapist time
required between f2f counseling and online modalities over eight weeks of treatment with
an average of 18 minutes of therapist time required for each online participant and 240
dependent on client satisfaction as clients are less likely to adhere to and benefit from
treatment if treatment is not satisfactory and/or does not meet client expectations. Initial
research in this area is quite limited due to small sample sizes and weak experimental
designs but suggests that clients are generally less satisfied with online counseling in
comparison to f2f counseling. In the most extensive study to date, Hanley and Reynolds
(2009) examined the online therapeutic alliance in adult therapy across five studies (N =
short form), each study reported high to moderate alliance scores suggesting that
participants felt enough connection with the clinician to enable therapeutic change
counseling program among college students, Richards (2009) reported lower client
difference between online counseling and f2f counseling when the reported mean online
client satisfaction score of 58 (out of 100) from Richards (2009) was compared to the
original mean validation score of 81 for f2f counseling from McMurtry and Hudson
videoconferencing technology was lower than students (n = 495) only receiving f2f
counseling. Collectively, these results illustrate the potential for therapeutic relationships
to develop in online mediums but that clients are possibly finding online counseling less
satisfying when compared to f2f counseling. Further research is warranted with better
potential use of online counseling services can provide important information about
people who may be interested in seeking online support and how to make these types of
services most accessible. A recent survey of 218 Australian community members (age
respondents endorsing a preference for using online mental health services and 77.1% of
respondents endorsing a preference for using traditional f2f counseling (Klein & Cook,
2010). Furthermore, online counseling use patterns have been identified by gender and
time spent using the internet for personal reasons. For example, Richards (2009) found
counseling (21% male and 79% female). Leibert et al. (2006) established a positive
22
correlation between general internet usage and the use of online counseling with
individuals who used the internet for more than 10 hours per week for personal reasons
Likewise, certain traits and attitudes predict preference for online counseling
versus traditional f2f counseling. Klein and Cook (2010) determined that people who
prefer online counseling in comparison to people who prefer f2f counseling hold stronger
stigmatized beliefs associated with accessing mental health services, place a lesser
chance to address mental health difficulties, and have lower extraversion, agreeableness,
counseling with the students receiving f2f counseling at the college counseling center
possible topics of interest for students interested in using online counseling (N = 252),
determined that time management and diet and exercise were priorities for students with
important areas for students experiencing high levels of distress and that work/life
balance was a topic of interest for all sampled students. These general use findings can
be of great value in developing online services and can help to tailor individualized
to outreach programs for college students showing signs of psychological distress and/or
being at risk for suicide. For example, Ryan et al. (2010) examined college students’
preference for formal and informal support as a function of level of psychological distress
(N = 251). The likelihood of student use of online mental health services positively
high psychological distress indicating that they were “quite likely” or “very likely” to use
they were “likely” to use online support; and 36.1% in the low distress indicating that
Initial interpretation of the findings proposed by Ryan et al. (2010) suggests that
online outreach services have the potential to reach students who are in need of support
but are unlikely to seek it without someone to facilitate the process of taking the first
step. Upon further examination however, the results also raise an important caveat from
one the most persuasive predictive theories, the theory of planned behavior (Ajzen,
factors that influence the behavior and volitional control of the behavior in question.
Application of the theory of planned behavior therefore suggests that actual rates
of online counseling use may differ from the intentions expressed by students if
motivational and/or volitional factors are not met. An individual’s intention to use online
24
counseling may involve motivational factors such as a need for psychological support,
the belief that online counseling may provide relief, and anonymity. Volitional control
factors may include an individual’s ability to contact a counselor and having a computer
Students have also shown willingness to use online counseling outside of the
college counseling center’s regular business hours and as a psychoeducational tool. For
students used the online service when the college counseling center was not open. More
than two-thirds of submission were emailed outside of the regular office hours, (Monday
to Friday 9:00am-5:00pm) was 77% (N = 34) (Richards, 2009). Furthermore, the use of
the website as a psychoeducational tool was also evident as the number of users increased
the 50 received submissions received 7,141 views by other users in the system with each
Consistent with the results of Richards (2009), Michaud and Colom (2003)
examined users’ overall satisfaction with and perceived usefulness of an internet health
information and an opportunity to ask personal questions which are then answered by a
trained professional. Out of the questionnaires completed by users who asked personal
questions (N = 257), 92% felt that the professional responding to their question had
clearly understood their problem. Moreover, the use of the website as a way to promote
25
healthier lifestyles was also clear as 55% of the respondents stated that they had changed
their behavior as a result of the suggestions they had received (Michaud & Colom, 2003).
In conclusion, the results of these two studies suggest that young adults have a significant
effectively with online practitioners and that online programs may be a worthwhile
addition for students who are unable or unwilling to utilize the college counseling
Online peer support. Online peer support groups may be another potentially
recently diagnosed with Bipolar Disorder and people who had been effectively managing
their Bipolar Disorder for at least two years, recently diagnosed individuals reported the
and provided practical information and advice (Proudfoot et al., 2009). At the college
level, such services could be an effective way to prevent relapse and encourage
pairing seniors and juniors with first year students or other students who just received a
diagnosis.
Conversely, however, Freeman, Barker, and Pistrang (2008) evaluated the use of
an online support group for college students (N = 238) with various psychological
concerns and found no evidence for the additional benefit of online peer support.
Participants with access only to a website containing information about student problems
and participants with access to an identical website and an online peer support group both
26
improved over time on two out of three outcome measures (Clinical Outcomes in Routine
Index) [Freeman et al., 2008]. Freeman et al. (2008) noted that the online peer support
group mirrored online groups that are professionally led (e.g., a few active members with
mostly silent readers) but that perhaps the results were skewed by the short length of the
study (10 weeks) [Freeman et al., 2008]. The authors suggest that the potential benefits
of an online support group were not identified in the study because the support group was
not yet functioning therapeutically. Accordingly, the mixed results of these two studies
highlight the need for further research to determine how long it takes for therapeutic
factors to develop in such a setting and whether peer online groups addressing specific
problems reported from students seeking counseling services, the potential of online
research area. Many students currently experiencing psychological distress are not
services out of a total of 344 respondents classified (using the General Population Well-
being Measure) to be at-risk for mental health problems (Cooke, Bewick, Barkham,
Bradley, & Audin, 2006). Initial research with students first trying online mental health
encouraging. For example, at a college counseling center that offered online services,
27
24% (n = 10) of users who interacted with a counselor by email went on to seek f2f
therapy, with an average of six months between using online services and meeting with a
counselor in-person (Richards, 2009). Likewise, Haas et al. (2008) noted that students
identified to be at-risk for suicide but who chose not to schedule an in-person evaluation
often acknowledged that online dialogues with a counselor made them more open to the
possibility of seeking f2f treatment in the future. Such findings provide further support
for the use of online counseling as an extension of current services being offered for
students who are hesitant or hold stigmatized beliefs toward mental healthcare.
therapy as treatment efficacy studies are showing positive results. Many of the remaining
regulations, clinical competency, and the lack of third-party payment options (Cartreine
et al., 2010; Kraus, 2010). State laws govern health care service delivery, and state
licensing boards for mental health professionals only allow clinicians to practice in the
state where the clinician is licensed (Kraus, 2010). Therefore, clinicians practicing online
counseling across state lines could encounter significant legal risk in a malpractice claim.
At the college level, these regulations limit the ability of counseling centers to provide
services to students who are not physically on campus such as when a student chooses to
travel abroad to another country. Unfortunately, online counseling could be quite useful
While state and federal regulations continue to be defined as malpractice suits are
Psychological Association (APA) briefly addresses online clinical concerns stating that
their general ethical standards also apply to psychological services delivered over the
internet (APA, 2010). The American Counseling Association (ACA) and the American
assisted counseling sections in their ethical codes clearly addressing specific issues
modify informed consent procedures for online use, the importance of attaining accurate
client identification, using encryption software, abiding by state and local regulations,
AMHCA, 2010). As clients have control over the location and type of computer used to
clinicians review how clients can maintain confidentiality (e.g., limiting access by others
to computer used for online therapy, double checking the email address before sending an
email, and having a discussion about encryption software and how to properly save email
Online counseling requires a skill set that extends beyond general graduate
behavioral health training programs. It is critical that both clinicians and potential
consumers become familiar with the various types of online treatments while
29
understanding the possible advantages and disadvantages associated with each modality
opportunities as full courses, continuing education credits, and seminars. Although the
ISMHO neither evaluates nor sanctions any specific training programs, the organization’s
clinicians to do further research into programs that are of interest (ISMHO, 2011). To
provide more rigorous training opportunities, Cartreine et al. (2010) recommend that
based treatments.
The cost of care is another factor limiting service utilization and the potential
growth of this field. The majority of clients seeking online services today pay out of
pocket using a credit card or other secure payment system such as PayPal (Cartreine et
al., 2010). In 2004, the possibility of third-party payment for established patients/clients
began with the insurance code 0074T which was then revised to code 99444 for
physicians and 98969 for non-physicians in 2008 (Zack, 2010). Federal health insurance
plans have followed allowing for people covered by Medicare Part B to receive Internet-
supported therapeutic interventions with audio and video equipment explicitly defined to
telephone, fax, and email (Health and Human Services Regulation on Telehealth, 2010).
Summary
Collectively, the reviewed literature supports the potential clinical utility of online
counseling and suggests that online mental health services may be a useful alternative for
30
people who are uncomfortable with or unable to access traditional f2f counseling.
willingness to at the very minimum try the new modality and the potential for clinicians
to have consistent clientele if people are satisfied with the service. One concern noted in
several studies, however, was the lack of user knowledge and understanding of what to
expect when engaging in online counseling. Klein and Cook (2010) stated that 54% of
sampled college students (n = 118) endorsed the statement “I would need to know more
about e-mental health services.” Likewise, when outlier scores were included in the
analysis of client satisfaction between f2f counseling and online counseling modalities,
Murphy et al. (2009) found higher client satisfaction scores for f2f counseling. Murphy
et al. (2009) attributed such differences to clients not having appropriate expectations of
problems that may arise when communicating with a counselor online (e.g., possible
technical issues and needing to find a quiet and secure space when responding to a
programs, client education will be essential with further discussion of possible services
and what to expect when engaging in online counseling prior to the start of treatment.
31
CHAPTER THREE
Student needs at college counseling centers are outpacing current resources. Key
organizations such as APA and the California higher public education systems and
professionals in the field are reevaluating how services can be best delivered. Discussion
practice standards. The initial research regarding online services (e.g., Barak et al., 2008;
Klein & Cook, 2010; Murphy et al., 2009; Richards, 2009) shows promising results in
terms of student interest and clinical effectiveness. With the need to maximize limited
resources among a large student body, university counseling centers are in a position to
take leadership. The first step in developing an online counseling program for the college
population is to assess college students’ attitudes and willingness to try online counseling
Based on the literature, the following hypotheses and research questions were
college students.
Hypotheses
indicate that men are less interested in and engage in online counseling less often than
women (Khasanhina et al., 2008; Klein & Cook, 2010; Richards, 2009).
32
2. It is hypothesized that participants who report conflicts in accessing the
college counseling center during regular business hours will be especially likely to
report interest in online services. The rationale for this hypothesis is based on previous
service was utilized by a significant number of students when the college counseling
3. It is hypothesized that participants who use the internet for more than 10
hours per week for personal reasons will report more interest in online counseling. This
who used the internet for more than 10 hours per week for personal reasons were more
likely to seek online counseling services than individuals who did not use the internet as
of f2f counseling, and belief in the value of online counseling will all correlate
that participants who displayed positive general help-seeking attitudes also expressed
positive views towards f2f counseling and online counseling (Rochlen, Beretvas, &
Zack, 2004).
Research Questions
and/or figurative language in email messages report more positive attitudes and interest in
online counseling?
33
2. In comparison to f2f counseling, do college students think online
counseling would permit greater control (e.g., when to initiate contact, pace and
support for symptoms related to social anxiety, including not having close friends and/or
METHODS
Participants
A total of 119 participants completed the survey, with Humboldt State University
(HSU) students comprising 77.3% (n = 92) of the sample and online respondents
comprising the remaining 22.7% of the sample (n = 27). Participants from HSU were
recruited through the psychology subject pool website and online participants were
blogs/meg-in-the-city/. The majority of the sample was female (71.4%, n = 85), White
(62.2%, n = 74), aged 18-25 (83.2%, n = 99), and had declared a social sciences major
(63.0%, n = 75). Participants took approximately 20-35 minutes to answer all of the
questions. Participants recruited from the subject pool received class credit for their
participation in the study. Participants from websites were entered in a raffle to receive
The ideal sample size for results involving group mean differences would have
been 132 participants, providing 90% power to detect a small-to-medium effect size of
.40. For correlational analyses, 113 participants would provide 90% power to detect a
medium effect size of .30. The achieved sample size of 119 provided the expected power
for correlational analyses and provided 85% power to detect an effect size of .40 for
A first draft of the survey was developed and revised with the aid of the HSU
Counseling and Psychological Services (CAPS) director. A pilot study was then
conducted on a group of five graduate students with a second revision phase to modify
Participants recruited from the subject pool completed the study in a psychology
research lab in the Behavioral and Social Sciences (BSS) building. Participants were first
script (see Appendix A for entire script) was read and participants were given an
opportunity to ask questions. Participants recruited from the websites completed the
survey online using Survey Monkey software. To raffle the gift certificates, participants'
email addresses were exported to a separate data file from the survey responses. This
eliminated any connection between the responses and the email addresses.
Measures
Due to the fairly recent introduction and study of online counseling, few
standardized measures exist to assess online counseling attitudes and potential utilization.
To adequately assess the current hypotheses and research questions there was a need to
create several questionnaires (see Appendices B and C for the complete survey).
to collect information about participants’ age, gender, ethnicity, sexual orientation, class
rank, and major. Items correspond to survey questions numbered one through six.
36
Counseling interest and experience scale. We created eight items for this study
to assess participants’ past, current, and possible future experiences with both f2f and
online counseling. Sample items include “I am interested in learning more about a) f2f
counseling, b) online counseling, and c) both types of counseling,” and “If I were to seek
counselor.” Items correspond to survey questions numbered 7-14. Items seven and eight
have a “check all that apply” response choice. A multiple choice response format was
used for items nine and 10. Participants responded to items 11 through 14 using a
(ATSPPHS; Fischer & Farina, 1995) which measures general attitudes toward seeking
professional help for psychological concerns. The scale is a 10-item shortened version of
an original 29-item instrument (Fischer & Turner, 1970) with a correlation between the
two scales of r = .87 (Fischer & Farina, 1995). Items with the highest item-total scale
correlations were chosen for the revised version. Sample items include: “The idea of
talking about problems with a psychologist strikes me as a poor way to get rid of
emotional conflicts” and “A person with an emotional problem is not likely to solve it
alone; he or she is likely to solve it with professional help.” Participants rate their level
of agreement with each of the items using a Likert scale ranging from 0 (strongly
disagree) to 3 (strongly agree). Responses are summed to yield a total score range of 0
to 30 with higher scores indicating a more positive attitude toward seeking psychological
37
help. Internal consistency reliability for the short form was found to be similar to the
documented values for the Full Scale with α = .84 (Fischer & Farina, 1995). When using
the ATSPPHS, Rochlen, Beretvas, and Zack (2004) found an internal consistency of α =
.75. The test-retest correlation with a 1-month interval between tests was r(32) = .80
(Fischer & Farina, 1995). The reliability coefficient found in this study for the
ATSPPHS was α = .68. This reliability coefficient is notably lower than the reliability
coefficients reported by Fischer and Farina (1995) but considered acceptable for the
the Online Counseling Attitudes Scale (OCAS) and the Face-to-Face Counseling
Attitudes Scale (FCAS) (Rochlen, Beretvas, & Zack, 2004) to compare attitudes between
f2f and online counseling. The OCAS is a 10-item questionnaire that assesses attitudes
toward online counseling with two subscales: Value of Online Counseling (OC-V) and
Discomfort With Online Counseling (OC-D). Sample items include “It could be
worthwhile to discuss my personal problems with an online counselor” and “If I were
having a personal problem, seeking help with an online counselor would be the last
option I would consider.” Participants rate their level of agreement with each of the
items using a Likert scale ranging from 1 (strongly disagree) to 6 (strongly agree).
Scores are calculated by summing the responses to each item from the two subscales,
with a score range of 5 to 30 for each subscale. High scores for the OC-V and the OC-D
indicate a positive view of online counseling and a high level of discomfort with online
counseling, respectively. Rochlen, Beretvas, and Zack (2004) reported test retest
38
reliability coefficients of r = .88 for the OC-V subscale and r = .77 for the OC-D subscale
while Rochlen, Land, and Wong (2004) reported test retest reliability coefficients of r =
.93 and r = .91 for the OC-V and the OC-D subscales, respectively. The reliability
coefficients for the OC-V and OC-D subscales of the OCAS in this study were α = .84
The FCAS is the same 10-item questionnaire as the OCAS except the word
“online” is substituted with the phrase “face-to-face” for all statements, and has the
With Face-to-Face Counseling (FC-D). For example, the sample items from the previous
problems with a face-to-face counselor” and “If I were having a personal problem,
seeking help with a face-to-face counselor would be the last option I would consider.”
Participants rate their level of agreement with each of the items using a Likert scale
summing the responses to each item from the two subscales, with a score range of 5 to 30
for each subscale. High scores for the FC-V and the FC-D indicate a positive view
toward f2f counseling and a high level of discomfort with f2f counseling, respectively.
The FCAS yielded test-retest reliability coefficients of r = .85 and r = .87 for the FC-V
and FC-D, respectively (Rochlen, Beretvas, & Zack, 2004). Across several studies both
the OCAS and the FCAS scales yielded internal consistency ranges of α = .77 to .90
(Rochlen, Beretvas, & Zack, 2004). The reliability coefficients for the FC-V and FC-D
39
subscales of the FCAS in this study were α = .90 and α = .82, respectively. Items
Computer and email comfort scale. We created seven items for this study to
assess participants’ computer skills and degree of comfort felt toward communicating by
email and online chatting. Sample questions include “I have the computer skills
communicate feelings by chatting online in ‘real time’ (e.g., instant messaging, video
were answered using a “disagree/agree” response choice. Item 51 asks about weekly
personal internet use and will be answered using a forced choice format.
college counseling center were to offer these services. Items ask participants about issues
for which online counseling may be sought, participants’ comfort and interest in using
interest in using expressive writing (e.g., emoticons, voice accentuations, acronyms, and
figurative language) to aid in written communication. Sample items include “An online
counseling program would be a good alternative for meeting my mental health needs”
and “Not being able to see my counselor’s facial expression(s) when reading my email
message would be okay.” The final item asks about participants’ interest in additional
methods of online counseling (e.g., discussion boards, chat room discussions, and peer
support groups).
40
Items correspond to survey questions numbered 52-72. Items 52-55 and item 72
have a “check all that apply” response choice. Participants responded to items 56-69
using an “agree/disagree” response choice format. Item 70 has a forced choice response
RESULTS
Consistent with the literature (e.g., Richards, 2009; Rochlen, Beretvas, & Zack,
with 28.9% of participants stating they had utilized online counseling and 64.4%
endorsing online counseling as a good alternative for their mental health needs. A total
of four hypotheses and five research questions were developed to explore interest in and
Bonferroni correction to reduce the risk of experimentwise error was not conducted, so
would be more interested in utilizing online counseling than men. To test this hypothesis,
two Chi-square tests were performed by gender for survey items #58 and #68. Survey
item #58 read: “An email online counseling program through the college counseling
center would be a good alternative for meeting my mental health needs (‘good
alternative’).” Survey item #68 read: “I would use email online counseling if I decided to
seek psychological support (‘would use email’).” No significant gender differences were
identified for either question. Females did not endorse email online counseling as a good
42
alternative for mental health services more often than men, nor did they indicate they
would use email online counseling more often than men (see Tables 1 and 2 for complete
statistical data).
Table 1
Relation of Gender, Access Conflicts, and Internet Time to Belief that Online
Counseling is a Good Mental Health Alternative
Variables X2 df n p V
Gender .462 1 118 .496 .063
Table 2
Relation of Gender, Access Conflicts, and Internet Time to
Use of Online Counseling if Psychological Support were Sought
Variables X2 df n p V
Gender .497 1 119 .481 .065
and discomfort with online counseling (OC-V and OC-D, respectively), and perceived
value and discomfort with f2f counseling (FC-V and FC-D, respectively) [These scales
were found by gender for two of these scales. In comparison to males, females displayed
more positive attitudes toward seeking professional help for psychological concerns and
perceived a greater value in f2f counseling. Females did not however, perceive a greater
value in online counseling than men and therefore, Hypothesis #1 was not supported (see
Table 3
Mean Differences for Counseling Attitudes Scales by Gender
Males Females
(n = 34) (n = 85)
Scales M SD M SD t p d
ATPPHS 17.22 3.00 19.74 3.92 3.362 .001** .72
counseling by students who are not able to access the college counseling center during
normal hours of operation was examined. It was hypothesized that participants who
reported conflicts in accessing the college counseling center during regular business
(Hypothesis #2). Statistical analyses first included two chi-square tests using survey
items #58 (good alternative) and #68 (would use email) between participants who
reported and did not report difficulties in accessing the college counseling center.
Participants who reported conflicts in accessing the college counseling center during
regular business hours (n = 29) identified email online counseling as a good alternative
mental health service more often than participants who did not report scheduling conflicts
with the college counseling center’s hours of operation. No significant differences were
identified between participants who reported and did not report difficulties in accessing
the college counseling center regarding intent to use email online counseling if
psychological support were sought (see Table 1 and Table 2 for complete Chi-Square
analyses).
Subsequently, an independent samples t-test for the OC-V subscale of the OCAS
was performed to identity possible group mean differences by this same grouping
parameter. The independent samples t-test for the OC-V subscale revealed no difference
participants who were able (M = 19.77, SD = 4.80) and not able (M = 19.72, SD = 4.50)
45
to access the college counseling center during normal business hours. Collectively, the
that participants who reported using the internet for more than 10 hours per week for
personal reasons would report more interest in online counseling than participants who
spent less time on the internet for personal reasons. To test this hypothesis, two Chi-
square tests were performed using survey items #58 (good alternative) and #68 (would
use email) and the following categories of participants’ reported weekly personal internet
use: < 1 hour, 1-3 hours, 4-6 hours, 7-9 hours, and 10 hours or more. Neither X 2 test
revealed significant results. Weekly personal internet use was not an important factor in
the endorsement of email online counseling as a good alternative mental health service
nor did it relate to willingness to use email online counseling if they sought psychological
Next, one Analysis of Variance (ANOVA) was conducted for the OC-V subscale
and the five weekly personal internet use categories. Results were again non-significant;
participant weekly personal internet use subgroups, F(4, 117) = 1.96, p = .11, η2 = .06.
the perceived value of f2f counseling and online counseling were investigated with the
prediction that general help-seeking attitudes, the perceived value of f2f counseling, and
46
the perceived value of online counseling would all correlate positively (Hypothesis #4).
To test this hypothesis, the ATPPHS was correlated with the FC-V subscale (perceived
value of f2f counseling) and the OC-V subscale (perceived value of online counseling).
A large significant correlation emerged between general help-seeking behavior and the
perceived value of f2f counseling. Likewise, a small but significant correlation was also
perceived value of f2f counseling (FC-V) and the perceived value of online counseling
(OC-V) did not correlate significantly. With two significant results, hypothesis #4 was
Table 4
Correlations for General Help-Seeking Attitude (ATTPHS), Perceived Value of f2f
Counseling (FC-V), and Perceived Value of Online Counseling (OC-V)
Measure 1 2 3
1. ATPPHS (.676)
2. FCV .498** (.898)
3. OCV .177* .107 (.844)
* p = .05. ** p < .01.
Note. Scale reliability values (Cronbach’s alpha) appear within parentheses.
Collectively, the results of the five hypotheses provide partial support for interest
in and belief in the perceived value of online counseling by this sample of college
students (N = 119). Specifically, the results suggest that email online counseling may be
a good mental health alternative for students who are unable to access the college
counseling center during normal business hours and/or would be interested in using the
counseling which contrasted with a much weaker correlation between general help-
seeking attitudes and the belief in the perceived value of online counseling. Similarly,
group mean differences by gender were found for general help-seeking attitudes and
belief in the perceived value of f2f counseling but not for belief in the perceived value of
online counseling. These findings suggest that online counseling may be beneficial to the
college population but that some hesitancy exists. For example, it is possible that online
was investigated by participants’ current email message writing style (Research Question
#1). Two independent samples t-tests were performed for survey item #55 and survey
items #58 (good alternative) and #68 (would use email). Survey item #55 read: “To help
me communicate through writing when I am online, I currently use (check all that apply):
figurative language.” To conduct mean comparisons, these six response choices were
added to make a writing style scale tallying the number of writing techniques participants
currently use when communicating online. The scale had a 0-6 score range. No
significant differences were found for either independent samples t-test. Participants who
used more writing style techniques (M = 3.37, SD = 1.56) did not endorse online
counseling as a good mental health alternative more often than participants who use
48
fewer writing style techniques (M = 3.05, SD = 1.73), t(116) = 1.053, p .30, d = .20.
counseling if psychological support were sought between participants who used more and
respectively, t(117) = .895, p = .37, d = .16. Subsequently, the OC-V subscale was
correlated with the writing style scale from survey item #55. Again the results were non-
significant indicating that use of writing style techniques is not an important factor in the
Question #2). Four independent samples t-tests were conducted with survey items #60-
63 and the OC-V subscale. Survey item #60 read: “Not being able to see my counselor’s
facial expression(s) when reading my email message would be okay.” Survey item #61
read: “Writing versus talking about my thoughts and feelings would allow me to be more
self-reflective.” Survey item #62 read: “I would feel more comfortable and be able to
express myself more openly in email online counseling versus face-to-face counseling.”
Survey item #63 read: “I would feel more in control of my counseling experience in
email online counseling versus face-to-face counseling (e.g., when to initiate contact,
client).”
Significant results were found for all independent samples t-tests. Participants
who agreed to the above survey items perceived a greater value in online counseling
49
(OC-V subscale) than participants who disagreed with the statements (see Table 5 for
complete results).
Table 5
Mean Differences for Perceived Value of Online Counseling (OC-V) by Counseling
Environment Variables
Agree Disagree
other modalities of therapy during a crisis was next assessed (Research Question #3).
agree to (check all that apply): provide accurate identification and emergency contact
telephone counseling session if my counselor thought it was necessary, and call a mental
risk.” Descriptive statistics for survey item #7 indicated that the majority of participants
would agree to several of the listed safety measures, including making more direct
Table 6
Percentage of Respondents Endorsing Willingness to Provide Contact Information and
Engage in Other Counseling Modalities if in Crisis
Endorsers
%
(n)
Provide accurate identification and emergency contact 77.3
information. (92)
N = 119.
51
Online counseling use as a psychoeducational tool. Research question #4
all students. Statistical analyses included two independent sample t-tests regarding the
perceived value of online counseling (OC-V subscale) participants who agreed versus
disagreed with survey items #59 (good alternative) and #65 (would use email). Survey
item #59 read: “Assuming my identifying information is removed, I would agree to have
my email message to a counselor and his/her response posted on an online webpage for
other students to view.” Survey item #65 read: “I would be interested in using email
generated, a final descriptive analysis was performed to identify participants who would
agree to use online counseling as a psychoeducational tool but would not be willing to
The majority of participants (62.2%, n = 74) agreed they would use email online
were found for both independent samples t-tests. Participants who expressed interest in
(OC-V subscale) than participants who did not express interest in such a service.
Likewise, participants who agreed that they would allow their correspondence with a
52
counselor to be posted online perceived more value in online counseling (OC-V subscale)
than participants who would not be comfortable with posting such an interaction (see
Table 7 for complete results). User generation of this psychoeducational tool was
promising; only one-third of participants (n = 25) who expressed interest in this resource
(n = 74) stated they would not be willing to post their own interactions with a counselor.
Table 7
Mean Differences for Perceived Value of Online Counseling (OC-V) by
Psychoeducational Tool Variables
Agree Disagree
seeking online support for symptoms related to social anxiety, including not having close
friends and/or being shy or uncomfortable in social situations, was examined (Research
Question #5). Descriptive statistics for survey items #58 (good alternative) and #68
(would use email) indicated that the majority of participants with social anxiety concerns
(n = 54) endorsed online counseling as a good mental health alternative (72.2%, n = 39)
and would consider using such a service if psychological support were sought (72.2%, n
= 39). Analysis also included four independent samples t-tests regarding the perceived
53
value of online counseling (OC-V subscale) and the perceived discomfort with online
counseling (OC-D subscale) for these two subgroups of participants. Significant results
were found for both OC-V independent samples t-tests. Participants who would consider
using email online counseling to address not having close friends perceived more value in
online counseling (OC-V subscale) than participants who would not use email online
counseling to address not having close friends. One significant result was found for the
OC-D subscale independent samples t-tests. Participants who endorsed interest in email
online counseling for being shy or uncomfortable in social situations perceived less
discomfort with online counseling (OC-D subscale), suggesting less discomfort with
online counseling than participants who did not express any interest in email online
may be an acceptable first step or addition to treatment given possible social limitations
and fear of meeting a therapist. Descriptive analyses were conducted for the two social
anxiety participant subgroups and survey items #66 and #67. Survey item #66 read: “I
would be interested in email online counseling while also attending weekly face-to-face
counseling.” Survey item #67 read: “If I had a good experience with email online
counseling I would likely seek face-to-face services in the future.” Results were
interest in concurrent f2f counseling and email online counseling, and were open to the
idea of f2f counseling in the future if they had a good experience with email online
55
counseling. Table 9 provides descriptive statistics for survey items #58, #68, #66, and
Table 9
Percentage of Respondents Interested in Online Counseling (OC) for Lack of Friends or
Social Discomfort Who Endorsed Counseling Interest Variables
Lack of Social
friends discomfort
(n = 24) (n = 30)
% %
(n) (n)
OC as good alternative 66.7 76.7
(16) (23)
A final objective of this research study was to provide useful information for
performed for interest in learning more about counseling services (survey item #10),
likelihood of experiencing anxiety if a counselor did not respond to an email right away
(survey item #69), length of time participants would be willing to wait for a counselor’s
response to an email message (survey item #70), text-based online counseling modality
preference (survey item #71), and interest in more advanced forms of online services
(survey item #72). The majority of participants were interested in learning more about
56
mental health services, with 63.0% of participants expressing a desire to learn more about
f2f and/or online counseling. A substantial number of participants (56.3%) also stated
they would feel anxious if a counselor did not respond to their email right away with
32.8% of participants would prefer to communicate with a counselor by email and 48.7%
Last, interest in more advanced online services (e.g., discussion boards, chat rooms,
video-conferencing, and online support groups) was also promising with participants
showing greater interest in services that were facilitated by a mental health professional
than strictly peer support without counselor input. Refer to Table 10 for these results
Table 10
Percentage of Respondents Endorsing Interest in
More Advanced Technology/Services
Identifying possible target groups of students for whom online counseling may or
may not be appropriate is another important aspect when developing online counseling
57
services. To explore this further, eight one-way ANOVAs were conducted for the OC-V
and OC-D subscales by participants’ age (survey item #1), sexual orientation (survey
item #4), past experience with f2f counseling (survey item #9), and interest in learning
more about f2f counseling and online counseling (survey item #10). All F-tests were
non-significant except for the OC-V subscale by interest in learning more about online
and f2f counseling. Post-hoc analysis revealed that participants who would be interested
learning more about f2f counseling and (M = 17.35, SD = 4.34), p = .001 and participants
who would not be interested in learning about either types of counseling (M = 17.56, SD
= 5.14), p = .012. As the significant F-test did not include participants who would be
interested in learning more about online counseling, these variables did not yield any
online counseling target groups. Results of these analyses are given in Tables 11 and 12.
58
Table 11
ANOVA Results for Perceived Value of Online Counseling (OC-V) by
Demographic and Counseling Related Variables
Table 12
ANOVA Results for Perceived Discomfort with Online Counseling (OC-D) by
Demographic and Counseling Related Variables
DISCUSSION
The purpose of this study was to explore college students’ knowledge of and
interest in online counseling services and factors that might relate to use by college
students. Results of the hypotheses and research questions provided partial support for
belief in the perceived value and interest in online counseling by this sample of college
students (N = 119). Consistent with the literature (e.g., Richards, 2009; Rochlen,
Beretvas, & Zack, 2004), participants appeared to have neutral to marginally positive
attitudes towards online counseling, an interest in various online services, and a desire to
seek out additional knowledge about and/or experience with online counseling.
for college counseling centers. Participants have specific preferences regarding the time
they would be willing to wait for a counselor’s email reply and interest in using more
counseling was appealing to some participants and provides useful information about
how online treatment may improve the quality of care for certain conditions.
identified regarding the belief in the perceived value and interest in online counseling.
Men and women expressed nearly equal ratings in their perceived discomfort and value
with online counseling (as measured by the OCAS scale) and potential use of online
services if psychological support were sought. These findings are consistent with the
60
results of the OCAS scale reported by Rochlen, Beretvas, and Zack (2004). A possible
explanation for these results relates to the emergence of online counseling as recently as
the 1990s and the fact that not enough time has elapsed for gender differences to become
evident. Another possible conclusion, also highlighted by Rochlen, Beretvas, and Zack
(2004), is that gender differences do not exist as the more distant nature of online
The lack of gender differences found in this study contradicts student use of online
more than males when compared to the gender breakdown of f2f counseling services
(Richards, 2009). This last finding suggests that online counseling parallels the gender
breakdowns traditionally found in f2f counseling and that this new modality of treatment
may not be an effective method to increase utilization of mental health services by men.
flexibility it offers for both clients and practicing clinicians (Leibert et al., 2006;
Recupero & Harms, 2010; Richards, 2009). This study’s results were consistent in that
participants who reported conflicts in accessing the college counseling center also
endorsed email online counseling as a good mental health alternative. These findings are
comparable to the considerable student use of online services at Trinity College outside
of the regular counseling center hours (Richards, 2009) and resembles the research of
Leibert et al. (2006) in which participants rated “flexibility” as the second highest
value of online counseling with this subgroup of participants was also identified. No
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significant differences were found for belief in the perceived value and expected
discomfort of online counseling (as measured by the OCAS scale) between participants
who were able and not able to access the college counseling center. This last finding
suggests a lack of understanding regarding how online counseling may be useful and
highlights the fact that interest in online services may not transfer to actual utilization if
The results also indicated that weekly time spent on the internet for personal
reasons is not an important factor regarding belief in the perceived value and interest in
online counseling. This finding contrasts with previous research in which Leibert et al.
(2006) determined that people who used the internet for more than 10 hours per week for
personal reasons were more likely to seek online mental health services than individuals
who used the internet less often. The results of this study most likely differ with Leibert
et al. (2006) simply because more people are using the internet at the present time. More
recently and consistent with the results of this study, Klein and Cook (2010) reported no
significant differences in access to technology (e.g., home internet access, public internet
participants who preferred traditional f2f counseling. This evidence suggests that
individuals who are interested in online counseling are not limited by technology and that
other factors (e.g., availability of services, insufficient experience with the modality, and
belief in the perceived value of f2f counseling and online counseling is another method
that has been used to examine interest in online counseling (Rochlen, Beretvas, & Zack,
2004). Consistent with the literature on f2f counseling (e.g., Deane & Todd, 1996), a
attitudes (as measured by the ATSPPHS) and the perceived value of f2f counseling (as
measured by the FC-V subscale). Interestingly, a much weaker but significant correlation
(r = .18) was found between general help-seeking attitudes (as measured by the
ATSPPHS) and belief in the perceived value of online counseling (as measured by the
OC-V subscale). These contrasting correlational values are comparable to the results
reported by Rochlen, Beretvas, and Zack (2004) (r = .43 to .64 between the ATSPPHS
and FCAS and r = .15 to.30 between the ATSPPHS and the OCAS), and suggests that
participants conceptualize the value of f2f counseling and online counseling differently.
The most likely explanation for these findings, also highlighted by Leibert et al. (2006),
is that certain qualities unique to online counseling, including increased client control and
disinhibition, are not adequately assessed by current online counseling measures. The
FCAS and OCAS are identical measures except for the phrase “face-to-face” is
substituted with the word “online” for all statements on the OCAS. If online counseling
specific survey items related to client control and disinhibition were incorporated into an
online counseling scale general help-seeking behavior may correlate more positively with
online counseling.
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This study additionally investigated several variables with limited research
including the use of expressive writing techniques, perceived client control in online
counseling, whether online users would provide emergency contact information, and
interest in using online counseling for social anxiety concerns. Drawing from the
professional opinion of Suler (2010), this study sought to explore how an individual’s
current use of various writing style techniques (e.g., emoticons, parenthetical expressions,
significant correlation was found between participants’ interest in online counseling (as
measured by the OC-V subscale) and use of writing style techniques, suggesting that
ability to communicate effectively with an online counselor is not a factor in the belief in
the perceived value of online counseling. Evaluation of these results within the context
of other research is limited and anecdotal (e.g., Fenichel, 2010; Suler, 2010) but does
question the notion that the modality requires a completely new skill set. It is likely that
the use of social networking sites (e.g., Facebook and online dating sites) and the
integration of email communication into everyday life has already provided potential
In terms of program development, this information indicates that the use of writing style
counseling.
literature (e.g., Haas et al., 2008; Richards, 2009; Rochlen, Zack, & Speyer, 2006; Suler,
2010) is the potential for increased client control. To examine this concept several
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survey items asked about participants’ comfort with not seeing the counselor’s face, if
they thought writing versus talking was more self-reflective, if they thought they would
be able to discuss their concerns more openly, and if they thought online counseling in
comparison to f2f counseling would allow for greater client control (e.g., when to initiate
and client). This study found significantly higher mean ratings for the OC-V subscale by
participants who believed online counseling permitted increased client control (with all
four client control variables) in comparison to participants who felt more in control with
f2f counseling. These findings are consistent with the research of Haas et al. (2008) and
Richards (2009) and suggest that some individuals are especially attracted to and find
value in online counseling because of the potential for increased client control. To assess
counseling scales incorporate items that evaluate perceived client control in online
modalities. A possible question might include “I would feel more comfortable and be
able to express myself more openly in email online counseling versus face-to-face
counseling.” Lastly, these results suggest a possible target group for this treatment
modality.
With over a 70% endorsement rate of several safety measures (e.g., accurate
identification and emergency contact information, immediate f2f counseling session and
immediate telephone counseling session), results from this study suggest that universities
can ethically consider online services within the realm of college counseling centers.
However, the fact that only 62.2% (n = 74) of participants endorsed that they would be
65
willing to provide their student identification number also indicates a level of concern
regarding how entering treatment may impact confidentiality and/or academic standing.
This uncertainty of how online services may impact privacy and educational goals was
also noted by Haas et al. (2008) in an interactive web-based outreach suicide program.
To increase the comfort level of the user, it appears students need confirmation that a
goal of the college counseling center is to support students so that they can remain in
suicide attempt, failing a majority of classes, and current child abuse of a minor sibling).
the OC-V subscale by participants who expressed interest in reading posted emails
between students and counselors and/or would be willing to post a personal interaction
with a counselor in comparison to participants who did not endorse an interest in such a
service, d = .52 and d = .59, respectively. These positive results mirror the experiences of
such a forum at Trinity College and on the “Ciao” health website for adolescents
(http://www.ciao.ch) (Michaud & Colom, 2003; Richards, 2009). Most notably, the
results highlight how a psychoeducational forum may act as a stepped care approach and
may improve the high student demand for counseling services. Both Michaud and Colom
(2003) and Richards (2009) reported how posted responses provided an individual with
decrease counselors’ case loads, provide another point of student contact, and be a good
interim solution for student waitlists. The high percentage of participants who expressed
a willingness to post their own interactions with a counselor in an online forum supports
online support for symptoms related to social anxiety. Participants who expressed
social situations in comparison to participants who would not use online counseling for
social anxiety displayed significantly higher ratings for belief in the perceived value of
online counseling (as measured by the OCAS scale). These results are very promising
given the increasing empirical support for online social anxiety programs (e.g., Andrews
et al. 2011; Tillfors et al. 2008) and the low utilization of f2f counseling by individuals
with social anxiety (Kessler, 2003). Most importantly, the results on social anxiety
indicated a willingness to use online counseling as a stepped care approach. Out of the
participants who would engage in online counseling for social difficulties, 67% (n = 36)
stated they could consider using email and f2f counseling concurrently and 81% (n = 44)
were open to the idea of seeking f2f counseling if they had a positive experience with
online counseling. These findings question and provide a possible solution to the
concerns raised by Leibert et al. (2006) regarding how clients may not apply
noteworthy strengths. For example, the use of three measures to assess general help-
counseling may fit into current f2f counseling treatment standards and replicates the work
of Rochlen, Beretvas, and Zack (2004), completed eight years ago. Frequent evaluation
of online services is essential due to the rapid progression of technology and new ways
people are integrating the internet into everyday life. Another strength of the study was
the inclusion of a brief description of online counseling and how it compares to f2f
age (Klein & Cook, 2010). Due to the current fiscal constraints and high student
demands for mental health services on college campuses, a final strength of the current
study was its focus on how online counseling may be applicable at the university level.
The development of several survey items by the researcher provided a way to examine
student interests and preferences if online services were offered by a college counseling
center and encourages discussion about how to best meet student needs.
Several limitations exist in the present study as well. First, participants were a
several websites frequently visited by college students, but that only generated an
HSU received the same amount of credit for their participation in the study regardless of
(general help-seeking attitudes, perceived value with f2f, and perceived value with online
counseling would all correlate positively) and the low internal consistency reliability
coefficient found for the ATSPPHS scale. A likely explanation for these discrepant
findings relates to the fact that the majority of participants took approximately 15-20
answered the survey too quickly at the expense of thoroughly reading and/or considering
The chosen research design introduces another limitation as the constructs were
measured by a single survey item. For example, participants were asked to determine
whether online counseling would be a good mental health alternative by the following
statement (survey item #58): “An email online counseling program through the college
counseling center would be a good alternative for meeting my mental health needs.”
Constructs measured by a single survey item considerably increases the chances for error
(e.g., not reading the question thoroughly, testing fatigue) and the difficulty in capturing
interest in and utilization of online services which does not necessarily translate to actual
future behavior. In context of the theory of planned behavior (Ajzen, 1985), this study
adequately assessed possible motivational factors for seeking online counseling (e.g.,
perceived value of online counseling as measured by the OCAS and researcher developed
survey items) but did not explicitly assess participants’ volitional control in utilizing
online services. Therefore, potential interest in online counseling is not likely to translate
to actual behavior for participants who found value in online counseling but did not
believe they had the personal will to actually utilize such services.
Clinical implications
Though this study has several inherent limitations, the findings are promising and
can be applied to clinical settings in a variety of ways. First, paralleling the results of
Klein and Cook (2010), the data demonstrate that online counseling is still a very new
form of mental health treatment that is not yet widely accepted or understood.
Participants’ belief in the perceived value of online counseling was lower than f2f
counseling and distinctly different. Although interpreting how individuals perceive f2f
counseling and online counseling differently is beyond the scope of this study, the results
indicate that more exposure and education about what online counseling entails is needed
for potential users. At the college level, an online counseling seminar could be
incorporated into new student orientation with additional tutorials found on the college
counseling center website. This outreach effort would not only make online counseling
70
easier to use but would also normalize the possible need for counseling when in college
because it is a time of transition with many unknowns and first time experiences.
Second, the findings indicate that despite some uncertainty, young adults have a
fairly positive view of online counseling and are especially attracted to the flexibility and
increased client control it offers. Sampled college students also displayed considerable
college counseling center is limited, and for issues in which seeking f2f counseling may
be too challenging. Ultimately, the results suggest that online counseling is a worthwhile
endeavor for college counseling centers to seriously consider while providing useful
As the demand for online mental health services increases, it will be imperative
that future studies continue to explore public attitudes and people most likely to be
information, general help-seeking attitudes, and past experiences with f2f counseling that
have been useful to identify possible candidates for f2f counseling (Gonzalez, Alegría,
Prihoda, Copeland, & Zeber, 2011; Silva & Blay, 2010), did not yield any viable target
groups for online counseling in this study. A greater understanding is needed of the
variables unique to internet modalities (e.g., lack of f2f cues, greater self-expression, and
user generated psychoeducational resources) that attract and/or discourage people from
seeking online support. Another key question is why and how people conceptualize f2f
counseling and online counseling so differently. Answers to this question will most
71
likely generate several hypotheses as to why people, including college students, are
hesitant to engage in this new modality of treatment. To address these research areas, it
is likely additional measures need to be created that get at the core value of online
information can also be gained from professionals in the field and clients who used online
counseling. Online mental health support is still in a trial and error phase of development
and many questions remain. The results of this study however, are promising in that it
demonstrates considerable interest and curiosity about the new treatment modality and
shows that online counseling is finding its place within the mental health field.
72
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APPENDIX A
To begin, thank you for your time and willingness to participate in this study conducted
by Chloe Brown, a graduate student in the HSU masters in counseling program. [The PI
who is conducting the study that day will then introduce her/himself.] Psychological
research is important because it often aids researchers and clinicians in developing new
scientific literature. Participation in the study is completely voluntary and you can
withdraw from the study without penalty at any time. You must be 18 years of age or
older for us to use your data in this study. Participation in this study is and will remain
completely anonymous so please do not put your name on any of the questionnaires or
forms. Upon completing the questionnaire please detach the last page of the packet to
take with you. If you are interested in the results of this study you may contact Chloe
Brown at a later date for more information. Do you have any questions?
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APPENDIX B
Participant Instructions
Participation in this study is completely voluntary and therefore you can withdraw
from the study at any point without penalty. By completing the following
questionnaires it is assumed that you are providing your consent to participate. Your
participation in this study will remain completely anonymous and therefore please
do not put your name on any of the questionnaires. In view of the fact that some of
the information being gathered is possibly of a personal nature, there is a potential risk
that you may experience some negative feelings. As a result, upon completion of the
questionnaires please detach the last page of this packet and take it with you. This
page includes information about local counseling services available to students as well
as other community members. We estimate that the questionnaires will take you
If you have any questions, please contact Chloe Brown either by phone at: (831) 917-
The following terms are used throughout the survey. Please carefully read the all
terms and their corresponding definition before continuing.
Please read each question carefully as the questions frequently change between
face-to-face and online counseling methods. There are no “wrong” answers, and the only
“right” answer is the one you honestly feel or believe. Thank you for your participation.
85
INSTRUCTIONS: For the following six statements, please circle the ONE best
answer that applies to you.
1. Age
a. 18-19
b. 20-21
c. 22-23
d. 24-25
e. 26 and older
2. Gender
a. Male
b. Female
c. Transgender
d. Other
3. Ethnicity
a. African American
b. Hispanic/Latino
c. Native American/Alaska Native
d. White/European-American
e. Asian American
f. Multiracial
g. Other
4. Sexual orientation
a. Heterosexual
b. Bisexual
c. Homosexual
d. Other
5. Class rank
a. Freshman
b. Sophomore
c. Junior
d. Senior
e. Graduate
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6. Major
a. Arts and humanities (e.g., English, journalism, philosophy, language, art,
music, and theatre)
b. Social sciences (e.g., political science, communications, anthropology,
psychology, sociology, and economics)
c. Natural sciences (e.g., biology, marine science, natural resources,
chemistry, physics, mathematics, and computer science)
d. Undecided
INSTRUCTIONS: For the following two statements, please check all boxes that may
apply.
Telephone counseling
Asynchronous contact (e.g., email)
Synchronous contact (e.g., instant messaging, video conferencing)
No experience with alternative counseling
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INSTRUCTIONS: For the following two statements, please circle the ONE best
answer that applies to you.
INSTRUCTIONS: Below are 4 statements with which you may agree or disagree.
Using the 0-1 scale below, indicate your agreement with each item by placing the
appropriate number in the line preceding that item. Please be open and honest in
your responding.
0 = Disagree
1 = Agree
two methods: (a) online counseling (where you would interact with a counselor using the
person). For the purpose of this study, consider having your choice of corresponding
with a counselor through emails or through an online “real time” text chat arrangement
such as Skype. A client using email counseling services would typically submit
questions or comments to a counselor and would receive a response within a short period
of time (typically 1-2 days). With online “real time” chat, you would have a set time
each week when you would meet in a private secure “chat room” to discuss concerns.
Please read the questions carefully because the sets of questions are similar. However,
the first 10 pertain to online counseling and the last 10 pertain to face-to-face counseling.
There are no “wrong” answers, and the only right ones are the ones you honestly feel or
believe.
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INSTRUCTIONS: Indicate your agreement with the following 10 statements on a
1-6 scale, where 1 = strongly disagree, 2 = disagree, 3 = somewhat disagree, 4 =
somewhat agree, 5 = agree, and 6 = strongly agree
0 = Disagree
1 = Agree
______48. I like chatting online in “real time” (e.g., instant messaging, video
conferencing).
______50. I have the computer skills necessary to communicate with a counselor through
an online “real time” text chat environment.
INSTRUCTIONS: Please respond to the following statement using the 1-5 scale
below.
1= < 1 hour
2 = 1-3 hours
3 = 4-6 hours
4 = 7-9 hours
5 = 10 hours or more
51. I use the internet for personal use (e.g., facebook, youtube, email, instant messaging,
and surfing the web) for___________ hours per week.
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INSTRUCTIONS: For the following four statements, please check all boxes that
may apply.
52. For what issue(s) have you previously sought or are you currently seeking
individual face-to-face counseling?
Relationship break-up
Depression
Anxiety
Questions/concerns about alcohol or drug use
Moodiness/emotions feel like a roller coaster
Eating too much and/or too little
Concerns about weight or appearance
Not having close friends
Being shy or uncomfortable in social situations
Death of a family member or friend
Legal or judicial concerns
Academic concerns (e.g., grades, major, study habits)
Fantasies about hurting someone else physically
Hurting someone else physically
Unwanted sexual experiences
Questions/concerns about sexuality
Questions/concerns about gender identity
Relationship concerns (e.g., with parent/s, partner, friends)
Financial concerns (e.g., budgeting, depending on others and no enough money for
education)
Chronic physical and/or mental health condition
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53. For what issue(s) might you seek email online counseling?
Relationship break-up
Depression
Anxiety
Questions/concerns about alcohol or drug use
Moodiness/emotions feel like a roller coaster
Eating too much and/or too little
Concerns about weight or appearance
Not having close friends
Being shy or uncomfortable in social situations
Death of a family member or friend
Legal or judicial concerns
Academic concerns (e.g., grades, major, study habits)
Fantasies about hurting someone else physically
Hurting someone else physically
Unwanted sexual experiences
Questions/concerns about sexuality
Questions/concerns about gender identity
Relationship concerns (e.g., with parent/s, partner, friends)
Financial concerns (e.g., budgeting, depending on others and no enough money for
education)
Chronic physical and/or mental health condition
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54. To help me communicate through writing when I am online, I currently use:
0 = Disagree
1 = Agree
56. I am available to seek services from the college counseling center during their
regular hours of operation (Mon-Fri 9am-5pm).
57. I have physical disabilities, language barriers, or access limitations that would
prevent me from accessing in-person services at the college counseling center.
58. An email online counseling program through the college counseling center
would be a good alternative for meeting my mental health needs.
59. Assuming my identifying information is removed, I would agree to have my
email message to a counselor and his/her response posted on an online webpage for other
students to view.
60. Not being able to see my counselor’s facial expression(s) when reading my
email message would be okay.
61. Writing versus talking about my thoughts and feelings would allow me to be
more self-reflective.
62. I would feel more comfortable and be able to express myself more openly in
email online counseling versus face-to-face counseling.
63. I would feel more in control of my counseling experience in email online
counseling versus face-to-face counseling (e.g., when to initiate contact, pace and
parameter of self-disclosure, power differential between professional and client).
64. I would save and likely review the email exchange between my counselor and
myself, more than once.
65. I would be interested in using email online counseling as psychoeducational
tool by reading the other students’ email communications (with identifying information
removed) on an online forum that is accessible to all students.
66. I would be interested in email online counseling while also attending weekly
face-to-face counseling.
67. If I had a good experience with email online counseling I would likely seek
face-to-face services in the future.
68. I would use email online counseling if I decided to seek psychological
support.
69. I would feel anxious if a counselor did not reply to my message right away.
98
INSTRUCTIONS: Please respond to the following statement using the 1-4 scale
below.
1= < 12 hours
2= 12-24 hours
3= 24-48 hours
4= 48-72 hours
INSTRUCTIONS: For the following question, please circle the ONE best answer
that describes your preference.
71. If I had a choice between email or instant message online counseling, I would
prefer:
a. Email
b. Instant message
c. No preference
99
INSTRUCTIONS: For the following statement, please check all boxes that may
apply.
Discussion boards (e.g., post an anonymous comment about a current concern and wait
for other students to reply)
Chat room discussions (e.g., engage in an anonymous “real time” discussion about a
current concern with other students who join the chat room)
Individual video-conferencing with a counselor (e.g., Skype)
Email based peer support group (no mental health professional and only peer group
members)
“Real time” peer support group (no mental health professional and only peer group
members)
“Real time” group counseling (one mental health professional with several group
members)
100
Please remove this page from the packet and take it with you
We wish to thank you for volunteering in our study. We recognize that some of
these questions might bring up some negative emotions. As such we also
recognize that some of the questions asked may be potential areas of concern
for you. People sometimes, while completing the questionnaires, become aware
of behaviors and thoughts that may suggest the need to talk to a professional or
seek out further information. If, after completing the questionnaires, you
recognize that there may be some issues or feelings that are a potential problem
for you, we strongly urge you to contact a professional to talk to about your
concerns or to answer questions that you may have.
The following agencies and resources are available for you to contact:
If you have any questions, please contact Chloe Brown either by phone at:
(831) 917-0379, or by email at: cbb26@humboldt.edu, or the supervising
professor, Dr. Beth Eckerd either by phone at: (707) 826-3757, or by email at:
beth.eckerd@humboldt.edu.
Once again, we thank you for your participation in this research project.
101
Please remove this page from the packet and take it with you
We wish to thank you for volunteering in our study. We recognize that some of
these questions might bring up some negative emotions. As such we also
recognize that some of the questions asked may be potential areas of concern
for you. People sometimes, while completing the questionnaires, become aware
of behaviors and thoughts that may suggest the need to talk to a professional or
seek out further information.
If, after completing the questionnaires, you recognize that there may be some
issues or feelings that are a potential problem for you, we strongly urge you to
contact a professional to talk to about your concerns or to answer questions that
you may have.
The following agencies and resources are available for you to contact:
If you have any questions, please contact Chloe Brown either by phone at:
(831) 917-0379, or by email at: cbb26@humboldt.edu, or the supervising
professor, Dr. Beth Eckerd either by phone at: (707) 826-3757, or by email at:
beth.eckerd@humboldt.edu.
Once again, we thank you for your participation in this research project.